The nurse cares for a client diagnosed with superficial partial thickness burn. The
nurse should assign the client to a room with which client?
A. A client diagnosed with Cushing’s Syndrome.
B. A client Diagnosed with
...
The nurse cares for a client diagnosed with superficial partial thickness burn. The
nurse should assign the client to a room with which client?
A. A client diagnosed with Cushing’s Syndrome.
B. A client Diagnosed with cellulitis of the left leg.
C. A Client diagnosed with acute peritonsillar abscess.
D. A client diagnosed with acute pelvic inflammatory disease.
Answer: A
2. The nurse observes client care on a geriatric unit. The nurse should intervene in
which situation?
a. A student nurse assist the client out of bed toward the clients strong side.
b. A student nurse assist the client to sit on the side of the bed by lifting the client’s
shoulders and swinging the client’s legs over the edge of the bed.
c. A student nurse assists the client to stand from a sitting position by grasping the
client’s elbows.
d. Two student nurses use a draw sheet to turn a client in the bed.
Answer: C
3. The nurse evaluates the results of the client’s purified protein derivative (PPD) 2 ½
days after the injection. The nurse noted the induration is 4 mm. which action by the nurse
is most appropriate?
a. Inform the client the results are negative
b. Obtain the names of the client’s closest contacts.
c. Determine the HIV status of the client.
d. Wait and additional 24 hours to read the results.
Answer: A
4. The nurse cores for the client with a history of schizophrenia. The nurse expects to
note which speech pattern?
a. Repetition of the words used by the nurse.
b. Rapid, coherent conversation about unrelated topics.
c. Immediately answering questions appropriately.
d. Slow, purposeful answers to the nurses questions.
Answer: A
5. The nurse cares for a 6-month-old infant. The parents report that the infant had
severe diarrhea for twelve hours. The nurse anticipates which finding?
a. Normal skin elasticity.
b. Depresses anterior fontanel.
c. Pale yellow urine.
d. Absent bowel sounds.
Answer: B
6. The nurse cares for a client receiving hydrocodone every 6 hours prn for pain. The
client reports pain at 1600. The nurse notes that the hydrocodone was last administered at
1200, and the nurse proceeds to administer hydromorphone at 1615. After discovering the
error, how should the nurse record the occurrence?
a. “Wrong pain tablet given early. Client will be monitored closely. Asleep now.”
b. “Hydromorphone given instead of hydrocodone. Nursing supervisor aware of error.”
c. Hydrocodone tablet ordered every 6 hours; pain medication given after 4 hours.
Health care provider notified.”
d. “Hydromorphone given at 1615; health care provider notified. B/P 122/80, RR 16.”
Answer: D
7. The male client asks the nurse, “Why am I experiencing erectile dysfunction (ED)?”
The nurse reviews the client’s medications. The nurse recognizes that which classification
increases the risk for ED?
a. Non-steroidal anti-inflammatory drugs.
b. Antihypertensive medications.
c. Anticoagulant medications.
d. Histamine H2 inhibitors.
Answer: B
8. The nurse in the hospital cafeteria overhears two nursing assistive personnel (NAP)
discuss the client’s condition. What is the PRIORITY action for the nurse to take?
a. Change the topic of the conversation.
b. Report the employees to their nurse manager.
c. Inform the employees about patient confidentiality and the client’s right to privacy.
d. Meet with the employees at the end of the shift and tell them not to discuss clients in
a public place.
Answer: C
9. The nurse cares for a client diagnosed with dehydration. The plan of care indicates
the client is to drink two ounces of fluid every hour. The nurse determines the goal is met if
which is recorded on the intake and output (I&O) sheet for an eight-hour shift?
a. 360 ml
b. 160 ml
c. 480 ml
d. 240 ml 1 oz=30 ml; 60 oz*8= 480 ml
Answer: C
10. The nurse and LPN/LVN care for clients on a medical-surgical unit. The RN should
delegate which activity to the LPN/LVN?
a. Follow up on the client’s report of chest and back itching two hours after starting a
patient controlled analgesia pump.
b. Provide instruction for the client receiving the first nicotine patch.
c. Inform the health care provider of the client’s history of peptic ulcer disease prior to
administration of streptokinase.
d. Take the blood pressure and heart rate before administration of enalapril.
Answer: D
11. The nurses care for the client diagnosed with tuberculosis. Before discontinuing
airborne precautions, the nurse must confirm which?
a. The tuberculin skin test is negative
b. No acid-fast bacteria are in the sputum.
c. The client has received anti-tuberculin medication for three days.
d. The client’s temperature has returned to normal.
Answer: B
12. The nurse cares for the client at 28 weeks gestation diagnosed with a complete
placenta previa. The nurse determines discharge teaching is effective if the client makes
which statement to her husband?
a. I can go back to work tomorrow on a part-time basis
b. I’m sorry to tell you we can’t have sexual relations
c. I will still be able to have a vaginal birth
d. I have to come back in 48 hours for a vaginal exam
Answer: B
13. The nurse prepares the client diagnosed with myxedema for discharge. Which
action should the nurse teach related to body temperature?
a. “Alternate acetaminophen with ibuprophen every four hours for fever”
b. “Take your temperature and record the results three times a day.”
c. “Put on multiple layers of clothes until you fell comfortably warm.”
d. “Use a heating pad during the day and electric blanket at night.”
Answer: C
14. The nurse cares for clients in the labor and delivery unit. The nurse anticipates
which client is a candidate for induction of labor?
a. The client with the fetal face as the presenting part.
b. The client diagnosed with preeclampsia.
c. The client diagnosed with active herpes infection.
d. The client experiencing late decelerations.
Answer: B
15. The nurse cares for the client diagnosed with HIV. The nurse determines which goal
is MOST important?
a. Prevent Kaposi’s sarcoma.
b. Prevent depression
c. Prevent infections.
d. Prevent social isolation.
Answer: C
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